Medical Power of Attorney (MPOA) Form

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Updated June 17, 2022

A medical power of attorney form (MPOA) allows a person (principal) to select an agent to make health care decisions on the principal’s behalf. The agent’s powers are effective after the principal becomes incapacitated or cannot make decisions on their own.

When making decisions, the agent must follow the principal’s preferred treatment options written in their Living Will (included in the MPOA).

Signing Requirements – Depends on the State where the Principal resides.

By State

Medical Power of Attorney: By State
What is a Medical Power of Attorney?
- Medical POA vs Living Will
- (Video)
Statutory Forms
Signing Requirements
How to Get Medical POA (4 steps)
How to Write a Medical POA
Related Forms

What is a Medical Power of Attorney?

A medical power of attorney (MPOA) is a designation made to select a person (agent or attorney-in-fact) to make health care decisions on behalf of someone else (principal).

If there is a dispute on whether the principal can make their own decisions, it will only go into effect after a licensed physician has deemed the principal incapacitated.

It’s recommended for a person that makes a medical power of attorney to also create a living will to write their treatment preferences for an agent to follow.

Medical POA vs Living Will

A medical power of attorney lets a person select their preferred treatment options with the use of choosing an agent to carry out their wishes. The agent will have full authority to make any type of decision to prolong or withdraw life-sustaining treatment.

A living will allows a person to select their preferred treatment options without the use of an agent. A living will directs medical staff their intentions to prolong or withdraw life-sustaining treatments depending on their condition.

(Video)

Statutory Forms

STATE	STATUTORY FORM	LAWS
Alabama	Advance Directive for Health Care	§ 22-8A-4(c)(4)
Alaska	Advance Health Care Directive	AS 13.52.010
Arizona	Health Care Power of Attorney	§ 36-3224
Arkansas	Durable Power of Attorney for Health Care	§ 20-6-103
California	Advance Health Care Directive	PROB § 4701
Colorado	Medical Durable Power of Attorney	§ 15-14-506
Connecticut	Appointment of Health Care Representative	Sec. 19a-575a
Delaware	Advance Health Care Directive	§ 2505
Florida	Designation of Health Care Surrogate	§ 765.202(1)
Georgia	Advance Directive for Health Care	§ 31-32-4
Hawaii	Advance Health Care Directive Form	§ 327E-16
Idaho	Living Will and Durable Power of Attorney for Health Care	§ 39-4510
Illinois	Durable Power of Attorney for Health Care	755 ILCS 35/3(b)
Indiana	Health Care Representative Appointment	755 ILCS 45/Art. IV
Iowa	Durable Power of Attorney for Health Care Decisions	§ 144B.5
Kansas	Durable Power of Attorney for Healthcare Decisions	§ 58-632
Kentucky	Advance Directive	§ 311.629
Louisiana	Medical Power of Attorney	RS 28:223
Maine	Health Care Advance Directive Form	§ 5-805
Maryland	Advance Directive	§ 5-603
Massachusetts	Health Care Proxy	§ 201D-2
Michigan	Durable Power of Attorney for Health Care	§ 700.5501(b)
Minnesota	Health Care Directive	§ 145C.16
Mississippi	Advance Health Care Directive	§ 41-41-209
Missouri	Durable Power of Attorney for Health Care	§ 404.822
Montana	Durable Power of Attorney for Health Care	§ 53-21-1304
Nebraska	Power of Attorney for Health Care	§ 30-3404
Nevada	Durable Power of Attorney for Healthcare Decisions	NRS 162A.860
New Hampshire	Advance Directive	Section 137-J:20
New Jersey	Medical Power of Attorney (proxy)	§ 26:2H-57
New Mexico	Advance Directive for New Mexico	§ 24-7A-4
New York	Health Care Proxy	PBH § 2981
North Carolina	Health Care Power of Attorney	§ 90-321
North Dakota	Health Care Directive	§ 23-06.5-17
Ohio	Health Care Power of Attorney	Section 1337.17
Oklahoma	Advance Directive for Health Care	§ 63-3101.4
Oregon	Advance Directive for Health Care	ORS 127.527
Pennsylvania	Durable Health Care Power of Attorney	§ 5471
Rhode Island	Durable Power of Attorney for Healthcare	§ 23-4.10-2
South Carolina	Health Care Power of Attorney	§ 62-5-504
South Dakota	Durable Power of Attorney for Health Care	§ 59-7-2.1
Tennessee	Advance Directive for Health Care	§ 68-11-1803(b)
Texas	Durable Power of Attorney for Health Care	§ 166.161
Utah	Advance Health Care Directive	§ 75-2a-117
Vermont	Advance Directive for Health Care	18 V.S.A. § 9703
Virginia	Advance Medical Directive	§ 54.1-2984
Washington	Durable Power of Attorney for Health Care	§ 11.125.100
West Virginia	Medical Power of Attorney	§ 16-30-4
Wisconsin	Power of Attorney for Health Care	§ 155.30
Wyoming	Advance Health Care Directive	§ 35-22-403

Signing Requirements

A witness cannot be a person that is related to the principal, agent or be a beneficiary in the principal’s last will and testament. If a notary is required, the notary may not act as a witness.

STATE	SIGNING REQUIREMENTS	LAWS
Alabama	Two (2) Witnesses	§ 22-8A-4(c)(4)
Alaska	Notary Public or Two (2) Witnesses	AS 13.52.010(b)
Arizona	Notary Public or One (1) Witness	§ 36-3221(A)(3)
Arkansas	Notary Public or Two (2) Witnesses	§ 20-6-103(c)
California	Notary Public or Two (2) Witnesses	§ 4701(e)
Colorado	No law (Notary Public recommended)	§ 15-14-506
Connecticut	Two (2) Witnesses	§ 19a-575
Delaware	Two (2) Witnesses	§ 2503(b)(1)(d)
Florida	Two (2) Witnesses	§ 765.202(1)
Georgia	Two (2) Witnesses	§ 31-32-5
Hawaii	Notary Public and Two (2) Witnesses	§ 327E-3(1)
Idaho	No law (Notary Public recommended)	§ 39-4510
Illinois	One (1) Witness	755 ILCS 45/4-5.1
Indiana	One (1) Witness	§ 16-36-1-7(b)(3)
Iowa	Notary Public or Two (2) Witnesses	§ 144B.3(b)
Kansas	Notary Public and Two (2) Witnesses	§ 58-632
Kentucky	Notary Public or Two (2) Witnesses	§ 311.625(2)
Louisiana	Two (2) Witnesses	§ 224 (A)
Maine	Two (2) Witnesses	§ 5-803(2)
Maryland	Two (2) Witnesses	§ 5–603
Massachusetts	Two (2) Witnesses	§ 201D-2
Michigan	Two (2) Witnesses	§ 700.5506(4)
Minnesota	Notary Public or Two (2) Witnesses	§ 145C.03(5)
Mississippi	Notary Public or Two (2) Witnesses	§ 41-41-205(2)
Missouri	Notary Public	§ 404.705(3)
Montana	Two (2) Witnesses	§ 50-9-103
Nebraska	Notary Public or Two (2) Witnesses	§ 30-3404(5)
Nevada	Notary Public or Two (2) Witnesses	NRS 162A.790
New Hampshire	Notary Public or Two (2) Witnesses	§ 137-J:14
New Jersey	Notary Public or Two (2) Witnesses	§ 26:2H-56
New Mexico	Two (2) Witnesses	§ 24-7A-4
New York	Two (2) Witnesses	PBH § 2981(2)
North Carolina	Notary Public and Two (2) Witnesses	§ 32A-16A(3)
North Dakota	Notary Public or Two (2) Witnesses	§ 23-06.5-05(d)
Ohio	Notary Public or Two (2) Witnesses	§ 1337.12(1)(b)
Oklahoma	Two (2) Witnesses	63 O.S. § 3101.4(A)
Oregon	Notary Public or Two (2) Witnesses	§ 127.515(2)
Pennsylvania	Two (2) Witnesses	§ 5452(b)(2)
Rhode Island	Notary Public or Two (2) Witnesses	§ 23-4.10-2(9)
South Carolina	Notary Public and Two (2) Witnesses	§ 62-5-517
South Dakota	Notary Public or Two (2) Witnesses	§ 34-12D-2
Tennessee	Notary Public or Two (2) Witnesses	§ 34-6-203(a)(3)
Texas	Notary Public or Two (2) Witnesses	§ 166.154
Utah	One (1) Witness	§ 75-2a-107(c)
Vermont	Two (2) Witnesses	§ 9703(b)
Virginia	Two (2) Witnesses	§ 54.1-2983
Washington	Notary Public or Two (2) Witnesses	§ 70.122.030
West Virginia	Notary Public and Two (2) Witnesses	§ 16-30-4(a)
Wisconsin	Two (2) Witnesses	§ 155.10(1)(c)
Wyoming	Notary Public or Two (2) Witnesses	§ 35-22-403(b)

Step 1 – Select Your Agent

The Agent that you select will have the responsibility of making your decisions based on your health care situation. Therefore you will want someone that you trust and is aware of your basic medical history (such as heart conditions, medication, allergies, etc.)

Successor (2nd) Agent – Individual selected only if the primary agent is not able to fulfill their duties. Co-agent authority is not usually allowed, must be the decision of 1 person.
Compensation – You have the option to set up compensation for the agent selected for lodging, food, and travel costs.

Step 2 – Agent’s Decisions

The decisions you give your agent related to your health care is up to you. You can allow your agent to make any type of decision that presents itself or you could limit your agent to only certain types of decision making. The more detailed you are as to what your agent can and cannot do will enhance the medical staff on your health intentions.

Example – Requesting the agent to refuse life support if there is little to no chance of a full recovery.

The following powers of the agent should be written:

Surgical Treatments
Nursing Home Treatment/Care
Hospitalization
Medical Treatment
Psychiatric Treatment
HomeStay Care
Organ Donation
End of Life Decisions

Step 3 – Attach a Living Will

A living will is a highly recommended option to be attached to any medical power of attorney. In addition to having someone speak on their behalf, a living will outlines a person’s end-of-life treatment selections.

For example, if a person should become in an incapacitated state with no chance for a cure, they can select to withhold life-sustaining methods to keep them alive. In addition, it allows the selection for organ donation and other post-death options.

Step 4 – Sign & Complete

The principal and Agent must sign in accordance with their respective State Signing Laws. In most cases, the form may be signed in the presence of two (2) witnesses or notary public, and sometimes both. After this has been legally authorized the document becomes valid to be used. The principal must be thinking freely during the creation of this form.

The Agent should carry an original copy of their form and will most likely need to present it during every occurrence. It is recommended to give a copy of this form to your primary care physician.

How to Write a Medical POA

Download in Adobe PDF (.pdf), Microsoft Word (.docx), or Open Document Text (.odt).

Step 1 – In Section I (Appointment of Health Care Agent) the principal and Agent full name and address. At the bottom of the section, the home phone, work phone, cell phone, and e-mail of the agent should be written.

medical-power-of-attorney-appointment-of-agent

Step 2 – In Section II the principal should include any exceptions (if any) from the broad powers the agent will have.

medical-poa-limitations-on-agent

Step 3 – In Section III, the principal has the option of selecting up to two (2) alternate agents in the chance individuals are unavailable for an act for the principal.

medical-poa-alternate-secondary-agent

Step 4 – In Section IV list the locations where originals and copies of this document will be held.

medical-poa-original-copies-where-held-location

Step 5 – In Section V, if the power of attorney will have an end period check the box and initial with the date that the form expires.

medical-poa-duration

Step 6 – On the last two (2) pages the individuals listed should sign the form in the presence of a notary public and/or two (2) witnesses that are not in any way connected (blood/marriage) with the parties authorizing the form.